Add New Patient

Full Name *

Patient ID Number *

Contact Number *

Date of Birth *

Gender *

Male

Female

Other

County *

Constituency *

Location *

Payment Type *

Individual

Hospital Referral

Insurance

Corporate

Individual Payment: Patient will pay directly for all services rendered.

Hospital Referral: Patient referred from another hospital. Bills will be sent to the referring hospital.

Referring Hospital *

Insurance Coverage: Patient covered by insurance. Claims will be submitted to the insurance company.

Insurance Company *

Policy Number *

Coverage Percentage

Percentage of bill covered by insurance (remaining will be patient's copay)

Corporate Coverage: Patient is an employee of a corporate company with medical coverage.

Corporate Company *

Employee Number *

Coverage Percentage

Percentage of bill covered by company (remaining will be employee's copay)

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